Common mental disorders and associated factors among final-year
healthcare students
EDMÉA FONTESDE OLIVA COSTA1*,MARGLEICE MARINHO VIEIRA ROCHA2, ANA TERESA RODRIGUESDE ABREU SANTOS3,
ENALDO VIEIRADE MELO4, LUIZ ANTONIO NOGUEIRA MARTINS5, TARCISIO MATOS ANDRADE6
1Adjunt Professor of Psychiatry, Department of Medicine; Federal University of Sergipe (DME/UFS); Dotorate in PPGMS/UFBA 2Graduate in Medicine (DME/UFS); Masters student, professional in Neurology of University of São Paulo of Ribeirão Preto (USP-RP)
3Medical Coordinator of Mental Health Juvenile Service of the teaching Hospital and the Psycho Pedagogic assistence service to medical students of the UFBA; Masters in PPGMS/UFBA 4Assistent professor at the department of medicine at the Federal University of Sergipe (UFS)
5Associate professor of psychiatry at the Federal University of São Paulo (UNIFESP)
6Associate professor of the Faculty of Medicine of Bahia and supervisor of the irst and third authors in the postgraduate program in health and medicine at the Federal University of Bahia (PPGMS/UFBA)
S
UMMARYStudy conducted at the Department of Medicine of the Federal University of Sergipe, Aracajú, SE
Article received: 3/18/2014
Accepted for publication: 6/3/2014 *Correspondence:
Universidade Federal de Sergipe Campus da Saúde Address: Rua Cláudio Batista, s/n Bairro Sanatório Postal Code: 49055-520 Aracajú -- SE edmeaolivacosta@gmail.com
Finantial support: none
http://dx.doi.org/10.1590/1806-9282.60.06.009
Conflict of interest: none
Objective: to assess the prevalence of common mental disorder (CMD) and to identify potential associated factors among medical, dental and nursing students.
Method: a cross-sectional study conducted in a public university in Northeast Brazil with 172 undergraduate students of the last three semesters of the medi-cine, dentistry and nursing courses, in February 2010, using the Self Reporting Questionnaire (SRQ-20) and a structured questionnaire developed by the au-thors. Logistic regression was performed for data analysis.
Result: the prevalence of CMD was 33.7%. The courses presented no differen-ces in CMD prevalence. The logistic regression analysis showed a strong asso-ciation of the following variables with CMD: female (OR=4.34), lack of good ex-pectations regarding the future (OR=5.83), course as not a source of pleasure (OR=7.52) and feeling emotionally tense (OR=11.23).
Conclusion: the high prevalence suggests that immediate preventive measures should be implemented, such as the setting up of psycho-pedagogic support ser-vices for students, and teacher development programs.
Keywords: mental health, mental disorders, students, dental, students, medi-cal students, nursing, occupational health.
I
NTRODUCTIONCommon mental disorders (anxiety, depressive and so-matoform disorders), also known as minor psychiatric disorders, are mild psychic troubles that, throughout the years, may cause great biopsychic and social impact.1
The-se disorders have symptoms such as: fatigue, insomnia, forgetfulness, dificulty in concentrating, irritability and somatic complaints.2 They also indicate relevant psychic
suffering and may lead to the development of more se-rious mental disorders, which seems particularly impor-tant in the case of healthcare professionals for their role in assisting the population.3-5
Medicine, dentistry and nursing are traditionally rec-ognized as being some of the most strenuous courses at university level as they demand great physical, intellectu-al and emotionintellectu-al effort from students. In the last year of
the undergraduate program, emotional exhaustion be-comes more evident and ends up predisposing the stu-dents to common mental disorder.3,6-11
We know from the literature that the prevalence of common mental disorder in industrialized countries rang-es from 7 to 30%.4 Similar studies drawn from the
Brazil-ian population, showed that this prevalence varied from 22 to 35%.12,13
At the same university, a recent study including only medical students revealed a high prevalence of common mental disorder (42.5%).14 To date, in this
Several studies have showed that institutions respon-sible for the training of health professionals should take cognizance of their students’ weaknesses regarding the educational process.15-18
This study aims to assess the prevalence of common mental disorder among the students of the last three se-mesters of the medicine, dentistry and nursing courses in a public university in Northeast Brazil and to identify the potential factors associated with this disorder.
M
ETHODSThe authors conducted a cross-sectional study in February 2010, in a public university from Northeast Brazil. The number of students per class when they were admitted into the university was: 40 for medicine, 20 for dentistry and 20 for the nursing course.
The medicine course follows the Brazilian tradition-al model for medictradition-al teaching comprised of 12 semesters: Basic Sciences Cycle (1st to 4th), Preparatory Clinical
Cy-cle (5th to 9th), and Internship (10th to 12th).
The dentistry course presents 10 semesters: Basic Sci-ences Cycle (1st to 4th), Preparatory Clinical Cycle (5th to
10th) and the Supervised Training Cycle (9th and 10th ).
The Nursing course includes 9 semesters: Basic Sci-ences Cycle (1st to 4th), Preparatory Clinical Cycle (5th to
8th) and the Supervised Training Cycle (9th semester).
All the 220 students of medicine, dentistry and nurs-ing regularly enrolled in the last three semesters of col-lege at the time of this survey were invited to participate, and 175 accepted the research terms.
Participants were required to answer two self-admin-istered questionnaires in the classrooms: the Self Report-ing Questionnaire (SRQ-20)1 and a speciic questionnaire
developed by the authors.
Before that, the teaching staff in each of the three cours-es received letters from the rcours-esearchers informing that a sur-vey would be carried out, and asking their permission to have the questionnaires applied during class time.
Every classroom was approached at least twice in or-der to get the maximum adhesion of the students to the survey. Students who did not return their questionnaires were considered missing.
The SRQ-20 is an assessment scale of anxious, depres-sive and somatoform symptoms developed by the World Health Organization (WHO). It was introduced by Hard-ing, in 1980, for screening minor psychiatric disorders in basic attention and was validated in Brazil by Mari.1,4 It is
a self-administered instrument with 20 binary response questions related to psycho-emotional symptoms, which showed satisfactory indexes in the studies conducted by
Mari, with sensibility and speciicity equal to 85 and 80%, respectively.1 The students answered the questionnaire
based on what they felt during the last 30 days. Scores high-er or equal to 6 for men and highhigh-er or equal to 8 for wom-en are considered as probable cases. This cutoff, according to the SRQ-20, was determined based on several studies.1,8,14
Although, this score does not implicate in formal diagno-sis, it indicates relevant psychic suffering that draws atten-tion to the mental health of healthcare professionals.
The structured self-administered questionnaire de-veloped and tested by the authors in an earlier pilot study consisted of 54 questions related to socio-demographic features, educational process and personal aspects.
The data analysis was performed using the SPSS sta-tistics software version 16.0. The analysis was done in three stages:
1st Population description through descriptive statistics
(inferential statistics is not suitable for this study, sin-ce the authors studied the population instead of a random sample);
2nd Bivariate and simple analysis, including the
construc-tion of tables and calculaconstruc-tion of crude odds ratio (OR) instead of prevalence ratio (PR) since OR is the mea-sure obtained in the logistic regression (inal step of our analysis) and can also be used in this type of study;
3rd Analysis of multiple variables by logistic regression.
The variables’ selection criteria are based on the variable’s importance in the literature, on the authors’ experience, and on the magnitude of the OR. The va-riables showing association with CMD >30% were kept in the inal model.
The outcome variable (common mental disorder) was ad-justed to the following predictive variables: sex, having a steady partner, religion, income, having another occupa-tion, course (socio-demographic features); satisfaction with the course choice, attitude toward the course, thoughts about dropping out the course, self-assessment of academic performance, self-assessment of skill acqui-sition needed to become a good professional, satisfaction with the teaching strategies, attitude toward the course’s activities, course as a source of pleasure (educational pro-cess); presence of physical disease, presence of mental di-sease, feeling emotionally stressed, reaction to conlicts, leisure time, emotional support, expectations about the future and feeling of happiness (personal aspects).
concealing identity throughout the study period, includ-ing durinclud-ing the completion of questionnaires.
R
ESULTSFrom all the 220 students enrolled in the last three se-mesters of the courses, 175 (79.5%) took part in the re-search: medicine (113), dentistry (47) and nursing (60). Three participants did not answer the SRQ-20, thus be-ing excluded from the study.
According to the cutoff point pre-established for male and female, the studied common mental disorder pre-sented a general prevalence of 33.7% (Table 1).
TABLE 1 Distribution of health care students according to socio-demographic variables and prevalence of common mental disorder; Public University, Northeast, Brazil, 2010
Variables N % CMD(%) Crude OR
Total 172 100 33.7
Sex
Female 108 62.8 43.5 3.71
Male 64 37.2 17.2 1
Steady partner
Yes 117 70.5 35.9 1.27
No 49 29.5 30.6 1
Missing 6
Religion
Yes 126 73.3 33.3 1
No 46 26.7 34.8 1.06
Family income (Minimum wage)
1 to 5 12 7.9 41.7 1.87
6 to 10 54 35.5 42.6 1.95
11 to 15 38 25 28.9 1.07
16 to 20 19 12.5 31.6 1.21
More than 20 29 19.1 27.6 1
Missing 20
Have other occupation
Yes 27 15.7 40.7 1.43
No 145 84.3 32.4 1
The studied population comprised predominantly fema-le (62.8%) and young (average age 23.5 ± 1.6) students. The majority (70.5%) had a steady partner, 73.3% practi-ced a religion, and 90.5% lived with relatives.
The majority (84.3%) did not have any other occupa-tion apart from being a student in that course, and most of them (35.5%) had a family income of 6 to 10 minimum wages (Table 1).
Concerning variables related to the educational process, 77.6% of the students considered the course to be a source of pleasure, and 79.1% believed that their academic perfor-mance was good or excellent. Although 87.7% thought that they were acquiring the skills necessary to become good pro-fessionals, only 29.3% were satisied with the teaching strat-egies used. In total, 94.7% of the students were satisied with their career choices, but 35.1% were uncomfortable with course activities and more than a half (56.4%) had thought of dropping out the course at least once.
With regards to personal issues, around half of the students dedicated less than 6 hours per week to leisure activities (50%), reacted aggressively or retracted them-selves in situations of conlict (51.5%), and considered themselves emotionally stressed (44.4%).
In terms of a personal support network, 80.2% report-ed that they were receiving the emotional support they needed, 82% had good expectations for the future, and 92.4% reported feeling happy.
On bivariate analysis of variables related to the educa-tional process, those students that had already thought of dropping out the course (OR=2.52) or felt uncomfortable in academic activities (OR=3.33) presented a greater associ-ation with the development of common mental disorders.
Concerning personal aspects, the probability of de-veloping a common mental disorder was higher among the students who considered themselves emotionally stressed (OR=10.60), who reacted to conlicts in a retract-ed or aggressive way (OR=2.89), who referrretract-ed the pres-ence of physical disease (OR=3.21), or mental disorder di-agnosed by a psychiatrist (OR=2.73).
The probability of developing CMD increased among the students who reported absence of suitable emotion-al support (OR=2.82), feeling unhappy (OR=13.11), and not so good expectations for the future (OR=8.71).
There were no signiicant statistical differences in the prevalence of CMD among students of medicine (30.1%), dentistry (36.8%) and nursing (39%) (Table 2).
TABLE 2 Distribution of health care students according to course and prevalence of common mental
disorder; Public University, Northeast, Brazil, 2010
Variables n CMD(%) Crude OR
Total 172 33.7
Course
Medicine 93 30.1 1
Dentistry 38 36.8 1.35
in the courses’ infra-structure and the educational mod-els adopted contributed to these results.
Four variables that showed strong association with common mental disorder were identiied after ad-justment by multiple logistic regression analysis.
In the international literature, having low income, be-ing female, not havbe-ing a steady partner, bebe-ing unemployed and practicing no religion are socio-demographic vari-ables that may be identiied as factors associated with common mental disorder.13,22,23
In this study, only females showed a strong associa-tion with common mental disorder after logistic regres-sion. This inding coincides with the literature that as-serts that women have higher prevalence of mental disorders and that CMD is the third health problem among females in developed countries and the ifth in undeveloped countries.13,24
Studies performed with others university students corroborate with these data. In medical schools in Teh-ran, female students were likely to develop psychic suf-fering in the same way that those who had very precari-ous inancial conditions.25 On the other hand, in Turkey,
a high association with depression among female and older students is seen.26
In other studies, CMD are more diagnosed in females because they look for health services more than males.22,24
In our study, the female sex variable showed strong asso-ciation with CMD after logistic regression, but the female frequency was also greater than male.
Other variables in our study that demonstrated strong association with CMD were: ‘not having good ex-pectations for the future’, ‘not seeing the course as a source of pleasure’ and ‘feeling emotionally stressed’. This may be explained by the inherent features of the academic atmosphere including tests and tight deadli-nes that are mainly sources of stress for the students. This inding coincides with the literature which points out emotional stress as an important associated factor to common mental disorder.15,17,27
The healthcare courses present certain peculiarities in the educational process that impact negatively the stu-dent’s physical and psychological health, cognitive func-tion and learning. These stressful factors include the prox-imity of death and innumerous pathological processes, excessive workload, competitiveness, fear of making mis-takes, late inancial independence and disappointment with the course, as well as privation of the family convivi-ality and leisure.18,23,28,29 Sleep problems have been
associ-ated with deicits in attention and academic performance, After adjustment using multiple logistic regression
analy-sis, the following variables were associated with common mental disorder: female sex, not having good expectations for the future, not seeing the course as a source of pleasu-re and considering oneself emotionally tense (Table 3).
TABLE 3 Outcome of the logistic regression for related variables and common mental disorder in healthcare students; Public University, Northeast, Brazil, 2010
Variables Crude OR Adjusted OR
Total 170
Sex
Female 3.71 4.34
Male 1
How do you consider yourself emotionally?
Calm 1
Tense 10.61 11.23
Course as a source of pleasure
Yes 1
No 2.07 7.52
Expectations for the future
Good 1
Not so good 8.71 5.83
D
ISCUSSIONThe general prevalence of common mental disorder among the students was higher than the rates found in general populations studied in industrialized countries.4
A survey carried out in Campinas, Brazil, using SQR-20, revealed a common mental disorder prevalence of 17% in the urban population.19 In Olinda, Brazil, a study
us-ing the same instrument revealed a 35% CMD rate among individuals aged 15 years or older.13
A study at the Pernambuco University-Brazil (UPE) among students of some health care courses found a gen-eral prevalence of CMD of 34.1%. The prevalence by course was: physical education (25%), nursing (31.8%), dentistry (33.3%), and medicine (42.6%).8 These results were
simi-lar to those found in our survey. Nevertheless, after com-paring only medicine courses in Brazil, we found that the prevalence of CMD in students of the course surveyed (30.1%) was smaller than the results of another earlier study by the author in the same university (42.5%) than those found at UPE (42.6%) and UNESP Botucatu (44.7%)8,14,19
drowsiness during classes, risk-taking behavior and depres-sion, impaired social relationships, and poorer health.30-32
Frequency of experiencing chronic illness, depression, anxiety disorder, seasonal affective disorder, mononucle-osis, and sleep dificulties were signiicant stress predic-tors.31-33 Students of medicine, dentistry and nursing
rep-resent a population with high educational level that is constantly exposed to this inhospitable environment, which may predispose them to a higher risk of develop-ing common mental disorder.9,14,16
Due to the workload of study and training that these courses require, students are also more inclined to devel-op burnout syndrome.9,32,34-36
Despite the high prevalence of CMD among the stu-dents assessed, only a small percentage (10.5%) had any mental trouble diagnosed by a psychiatrist. In the same way, in a universe of 7,357 students from 36 medical schools of South Korea, 689 students presented depres-sion and, out of these, only 9.7% were diagnosed and sub-mitted to psychiatric treatment.37
This situation of under diagnosis may be motivated by the lack of a support service to the mental health of students in the universities.
Even the students of medicine, dentistry and nurs-ing courses that studied with the most recognized health teams from the best universities in Brazil had their men-tal health very neglected by these institutions since no healthcare and psycho-pedagogical support service was made offered to the students.5 Many medical schools,
es-pecially in South and Southeast Brazil, have estab-lished psycho-pedagogical support services in the last years; however, in Northeast Brazil, this hasn’t occurred in the same proportion.28
In the USA, most colleges and universities have now developed mental health and counseling programs com-mensurate with the size of their student bodies, although yet in 1957 the American College Health Association formed a Mental Health Section to serve mental health profession-als, 37 years after the American Student Health Associa-tions annual meeting in 1920 had identiied “mental hy-giene” as critical for college campuses to assist students to reach their highest potential. Indeed, the irst student health service is credit to Amherst College in 1861.38
Regarding the issues of the educational process, we can observe that, although most students feel satisied with their course choices and feel comfortable with their courses’ ac-tivities, more than half of them is not satisied with the teach-ing strategy and at least once considered to drop out the course. Nevertheless, these variables did not maintain a strong association with CMD after logistic regression.
The cross-sectional design of our study has a limitation, which is the simultaneous analysis of both exposure and outcome, preventing us from establishing causal relations among the associations found. On the other hand, the pur-pose of this study was restricted to assess the answers given to the questionnaires that aim to detect symptoms of CMD and not to establish a formal diagnosis. For this reason, fur-ther longitudinal studies including a qualitative stage with psychiatric interview are required for a more accurate dei-nition of the problem outcome found in our study. Despite these limitations, the study suggests hypotheses and sup-plies important data for preventive measures to be adopted.
C
ONCLUSIONConsidering all the above, it is evident that the mental health of those who will soon become healthcare suppliers for the population needs more attention.
There was no difference regarding CMD prevalence among the students of medicine, dentistry and nursing in the university surveyed. This population showed a high prevalence of CMD and more than its half was discon-tent with the teaching strategies adopted, having thought at least once about dropping out the course. Furthermore, the majority considered the course chosen as a source of pleasure and had good expectations for the future.
The high prevalence of common mental disorder found by the researchers suggests that preventive mea-sures must be immediately implemented such as: psycho-pedagogical support services for students and lecturers, development courses for the teaching staff, and a health-ier environment to improve interpersonal relationships. In addition, we also suggest the raising of awareness among future healthcare professionals regarding the im-portance of maintaining their physical and mental well-being, which impact positively in the patient assistance.
Longitudinal studies assessing this theme at the re-searched university and other universities that have a pop-ulation with similar proile are necessary aiming to iden-tify the causal factors of common mental disorder among students from health-related courses.
R
ESUMOTranstornos mentais comuns e fatores associados entre estudantes de saúde do último ano.
Métodos: estudo transversal realizado em uma universi-dade pública no Nordeste do Brasil com 172 alunos de graduação dos últimos três semestres de Medicina, Odon-tologia e Enfermagem, em fevereiro de 2010, utilizando o Self Reporting Questionnaire(SRQ-20) e um questio-nário estruturado desenvolvido pelos autores. A análise dos dados foi realizada por regressão logística.
Resultados: a prevalência de TMC foi de 33,7%. Os cur-sos não apresentaram diferenças na prevalência de TMC. A regressão logística mostrou uma forte associação entre as seguintes variáveis com TMC: sexo feminino (OR=4,34), não ter boas expectativas em relação ao futuro (OR=5,83), curso não ser uma fonte de prazer (OR=7,52) e sentir-se emocionalmente tenso (OR=11,23).
Conclusão: a alta prevalência de TMC sugere que medi-das preventivas imediatas devam ser implementamedi-das, como: a criação de serviços de apoio psicopedagógico para alu-nos e programas de desenvolvimento docente.
Palavras-chave: saúde mental, estudantes de odontolo-gia, saúde do trabalhador, estudantes de medicina, estu-dantes de enfermagem, transtornos mentais.
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EFERENCES1. Mari JJ, Williams P. A validity study of a psychiatric screening questionnaire (SRQ-20) in primary care in the city of Sao Paulo. Br J Psychiatry. 1986;148:23-6. 2. Goldberg DP, Huxley P. Common mental disorders a bio-social model. London:
Tavistock/Routledge; 1992.
3. Birks Y, McKendree J, Watt I. Emotional intelligence and perceived stress in healthcare students: a multi-institutional, multi-professional survey. BMC Med Educ. 2009;9(1):61.
4. Harding TW, de Arango MV, Baltazar J, Climent CE, Ibrahim HH, Ladrido-Ignacio L, et al. Mental disorders in primary health care: a study of their frequency and diagnosis in four developing countries. Psychol Med. 1980;10(2):231-41. 5. Meleiro AM. [Suicide among physicians and medical students]. Rev Assoc
Med Bras. 1998;44(2):135-40.
6. Benjakul P, Cheunarrom C. Student adjustment problems in two dental schools in Thailand. J Dent Educ. 2000;64(5):365-9.
7. Burnard P, Haji Abd Rahim HT, Hayes D, Edwards D. A descriptive study of Bruneian student nurses perceptions of stress. Nurse Educ Today. 2007;27(7):808-18.
8. Facundes VL, Ludermir AB. Common mental disorders among health care students. Rev Bras Psiquiatr 2005;27(3):194-200.
9. Gorter R, Freeman R, Hammen S, Murtomaa H, Blinkhorn A, Humphris G. Psychological stress and health in undergraduate dental students: ifth year outcomes compared with irst year baseline results from ive European dental schools. Eur J Dent Educ.2008;12(2):61-8.
10. Heath JR, Macfarlane TV, Umar MS. Perceived sources of stress in dental students. Dent Update.1999;26(3):94-8,100.
11. Tyssen R, Vaglum P, Gronvold NT, Ekeberg O. Factors in medical school that predict postgraduate mental health problems in need of treatment. A nationwide and longitudinal study. Med Educ. 2001;35(2):110-20. 12. Lima MS, Beria JU, Tomasi E, Conceição AT, Mari JJ. Stressful life events
and minor psychiatric disorders: an estimate of the population attributable fraction in a Brazilian community-based study. Int J Psychiatr Med. 1996;26(2):211-22.
13. Ludermir AB, Melo Filho DA. [Living conditions and occupational organization associated with common mental disorders]. Rev Saúde Pública. 2002;36(2):213-21.
14. Costa EF, Andrade TM, Silvany Neto AM, Melo EV, Rosa AC, Alencar MA, et al. Common mental disorders among medical students at Universidade Federal de Sergipe: a cross-sectional study. Rev Bras Psiquiatr. 2010;32(1):11-9. 15. Divaris K, Barlow PJ, Chendea SA, Cheong WS, Dounis A, Dragan IF, et al.
The academic environment: the students perspective. Eur J Dent Educ. 2008;12(Suppl 1):120-30.
16. Lloyd C, Musser LA. Psychiatric symptoms in dental students. J Nerv Ment Dis. 1989;177(2):61-9.
17. Seyedfatemi N, Tafreshi M, Hagani H. Experienced stressors and coping strategies among Iranian nursing students. BMC Nurs. 2007;6:11. 18. Wexler M. Mental health and dental education. J Dent Educ. 1978;42(2):74-7. 19. Lima MC, Domingues MS, Cerqueira AT. [Prevalence and risk factors of
common mental disorders among medical students]. Rev Saúde Pública. 2006;40(6):1035-41.
20. Almeida AM, Godinho TM, Bitencourt AGV, Telles MS, Silva AS, Fonseca DC, et al. Common mental disorders among medical students. J Bras Psiquiatr. 2007;56(4):245-51.
21. Benvengnú LA, Deitos F, Copette FR. Problemas psiquiátricos menores em estudantes de medicina da Universidade Federal de Santa Maria, RS. Rev Psiquiatr Rio Gde Sul. 1996;18(3):229-233.
22. Marin-Leon L, Oliveira HB, Barros MB, Dalgalarrondo B, Botega NJ. Social inequality and common mental disorders. Rev Bras Psiquiatr. 2007;29(3):250-3. 23. Omigbodun OO, Odukogbe AT, Omigbodun AO, Yusuf OB, Bell TT, Olayemi O, et al. Stressors and psychological symptoms in students of medicine and allied health professions in Nigeria. Soc Psychiatry Psychiatr Epidemiol. 2006;41(5):415-21.
24. Rodrigues-Neto JF, Figueiredo MFS, Faria AAS, Fagundes M. Transtornos mentais comuns e o uso de práticas de medicina complementar e alternativa: estudo de base populacional. J Bras Psiquiatr.2008;57(4):233-9. 25. Shariati M, Yunesian M, Vash JH. Mental health of medical students: a
cross-sectional study in Tehran. Psychol Rep. 2007;100(2):346-54.
26. Kaya M, Genc M, Kaya B, Pehlivan E. [Prevalence of depressive symptoms, ways of coping, and related factors among medical school and health services higher education students]. Turk Psikiyatri Derg. 2007;18(2):137-46. 27. Compton MT, Carrera J, Frank E. Stress and depressive symptoms/dysphoria
among US medical students: results from a large, nationally representative survey. J Nerv Ment Dis. 2008;196(12):891-7.
28. Millan LR, Arruda PC. [Psychological assistance to medical students: 21 years of experience]. Rev Assoc Med Bras. 2008;54(1):90-4.
29. Finger G, Silva ER, Falavigna A. Use of methylphenidate among medical students: a systematic review. Rev Assoc Med Bras. 2013;59(3):285-9. 30. Gaultney JF. The prevalence of sleep disorders in college students: impact
on academic performance. J Am Coll Health. 2010;59(2):91-7.
31. Costa EF, Santana YS, Santos AT, Martins LA, Melo EV, Andrade TM. [Depressive symptoms among medical intern students in a Brazilian public university]. Rev Assoc Med Bras. 2012;58(1):53-9.
32. Leao PB, Martins LA, Menezes PR, Bellodi PL. Well-being and help-seeking: an exploratory study among inal-year medical students. Rev Assoc Med Bras. 2011;57(4):379-86.
33. Dusselier L, Dunn B, Wang Y, Shelley MC 2nd, Whalen DF, et al. Personal,
health, academic, and environmental predictors of stress for residence hall students. J Am Coll Health. 2005;54(1):15-24.
34. Baldassin S, Silva N, de Toledo Ferraz Alves TC, Castaldelli-Maia JM, Bhugra D, Nogueira-Martins MC, et al. Depression in medical students: Cluster symptoms and management. J Affect Disord. 2012;150(1):110-4. 35. Costa EF, Santos SA, Santos AT, Melo EV, Andrade TM. Burnout syndrome
and associated factors among medical students: a cross-sectional study. Clinics. 2012;67(6):573-80.
36. De Abreu Santos AT, Grosseman S, de Oliva Costa EF, da Andrade TM. Burnout syndrome among internship medical students. Med Educ. 2011;45(11):1146.
37. Roh MS, Jeon HJ, Kim H, et al. Factors inluencing treatment for depression among medical students: a nationwide sample in South Korea. Med Educ. 2009;43(2):133-9.
